The notion that we will have to live with COVID as a new human pathogen is perhaps just sinking in to the general population. If you want an update, check out Mark Crislip’s new post (it’s great to have Mark back at SBM – his dry humor was missed). I have long resigned myself to the notion that we are basically never going to get back to the pre-COVID normal. Likely, routine masks are now the new normal in health care. During my career once a new infectious precaution is added it never goes away.

It is possible that humanity will also have to get used to the idea of not just living with COVID, but living in a world in which pandemics happen with increasing frequency. I don’t think it will be another century before the next COVID, and there are much worse things than COVID lingering on the edges of civilization, waiting for their chance. COVID should be a wake-up call, and in an even semi-rational world would lead to a much more robust international effort to limit zoonosis (infections spreading from animals to humans), rapidly responding to novel outbreaks, and vaccinating everyone.

Speaking of which, you may have seen reports that a new virus is being reported in different parts of the world, the monkeypox. The World Health Organization (WHO) recently reported 250 confirmed cases in 16 different countries. This includes (as of May 23) 20 confirmed cases in the UK, with one confirmed and four suspected cases in the US. Pre-COVID an outbreak like this would barely register. Now, outbreaks understandably make people a little twitchy. I remember in February 2020 the “voices of reason” were saying about COVID (myself included) that we should be concerned, but it’s too early to panic. I don’t know if in retrospect that struck the right tone (without Monday morning quarterbacking), but it feels like we are in the same place now with the monkeypox.

Any new zoonotic outbreak should be taken seriously, and is cause of concern, but we cannot panic every time it happens. It would help if we could all feel confident that those in charge will respond appropriately, and they will tell us if we need to take any precautions. Right now the WHO is not recommending any lockdowns or special measures. They are characterizing these outbreaks as “containable”. That’s reassuring, but let’s take a look at monkeypox to hopefully have a better idea how concerned we should be.

The monkeypox is not new, it is a known virus closely related to smallpox. Smallpox was a scourge of humanity declared eradicated from the world in 1980, due to a robust vaccination campaign. Monkeypox is a virus, a member of the Orthopoxvirus genus in the family Poxviridae – the same genus as smallpox. As the name implies, it is zoonotic, transmitting from animals to humans. It is less contagious than smallpox and causes less severe illness, typically a rash, fever, and inflamed lymph nodes lasting 2-4 weeks. The fatality rate depends on the strain, and ranges from 0-10%, with the WHO stating 3-6% on average. While that may be relatively low, it is still concerning, especially if one of the more virulent strains breaks out.

Monkeypox was first identified in the Congo in 1970, and most outbreaks since then have been in Africa. This is why the recent outbreaks have perked the interest of experts, as it is spreading outside its usual range. Another cause of concern is that, as we all learned from tracking COVID, the reports of confirmed cases is likely a couple weeks behind reality. So by the time we know of outbreaks in other countries, the virus has likely already spread even farther.

There is good and bad news on the vaccine font. The good news is that the smallpox vaccine conveys about 85% coverage of the monkeypox. So we already have effective vaccines and many people are vaccinated. However, the bad news is that if you are under age 45 you are likely not vaccinated because smallpox was eradicated. But, more good news, Moderna (one of the mRNA companies) is already working on a specific monkeypox vaccine.

Monkeypox is spread mostly through direct physical contact with bodily fluids, but also through contact with contaminated surfaces, and through droplets. A 2013 study also found that aerosolized monkeypox can remain infective for up to 90 hours, but this may not be a significant mode of transmission. It seems, therefore, that masking, avoiding physical contact, cleaning surfaces, and social distancing can be highly effective, and is partly why the WHO feels recent outbreaks can be contained. This can also be combined with contact tracing.

Given all this, should we fear the monkeypox? Yes and no. Right now outbreaks are limited and containment is possible. We have methods of preventing and treating monkeypox. This is exactly the scenario for which we need a robust international rapid-response capability, to nip these outbreaks in the bud before they become epidemics or pandemics. But we need to keep our eye on the situation, because we also know how quickly they can get out of control. Outbreaks like this have always been going on the background, while the general public is mostly unaware or pays little attention. The main difference now is that we are paying attention.

I also firmly believe that COVID should have taught us that we need to radically change the conversation around vaccines, and if we needed it the monkeypox may be a potent reminder. Vaccines are our best defense against a world in which viruses and other agents are constantly evolving in order to exploit a large human population with frequent global travel. The world is essentially a petri dish for infections, and we have also made ourselves more vulnerable by getting too cozy with wildlife populations. We need the protection that only vaccines can provide.

Tolerance for anti-vaccine lies and propaganda needs to be a thing of the past. We need to aggressively marginalize and counter antivaccination views. This also needs to be paired with far greater vaccine requirements. While I don’t agree with forced vaccination (which is likely not feasible in any case), it is completely reasonable (given the reality I outlined above) to make it very difficult to live in this world as someone who refuses to do their common sense duty to protect themselves and others with vaccination. It’s your choice, but now you have to stay over there away from everyone else (metaphorically speaking). Clearly such regulations need to be on the federal level (and when it comes to travel on an international level) – universality is the whole point.

Either that or we need to accept the fact that we live in pandemic world.

Author

  • Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.

Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.